jnc – 8 jim hoehns, pharm.d

JNC – 8

Jim Hoehns, Pharm.D.

Evidence Review Randomized controlled trials Adults ≥ 18 years old with hypertension N >100 Duration: ≥ 1 year Outcomes

Mortality, CVD related-mortality, CKD-related mortality MI, HF, hospitalization-HF Coronary or other revascularization ESRD▪ KF resulting in dialysis or transplantation, doubling of Cr value, halving of

GFR

3 Questions

In adults with HTN, Does initiating antihypertensive drug

therapy at specific BP thresholds improve health outcomes?

Does treatment with antihypertensive drug therapy to a specified goal lead to improvement in health outcomes?

Do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?

Question 1• 45 y.o. white female• Hx: HTN, hyperlipidemia, MDD• Meds: Atorvastatin 20mg QD, Fluoxetine 20mg QD• BP: 150/96, HR: 73Treatment:1. Lisinopril 10mg

QD2. Amlodipine 5mg3. HCTZ 12.5-25mg

QD4. Metoprolol BID

100 0 0 0

Question 2•64 y.o. white male• Hx: CKD, HTN, hyperlipidemia• Meds: simvastatin 20mg QD, ASA 81mg QD, lisinopril 20mg QD• Labs: Cr = 1.9, K+ = 4.8, Est Clcr = 38 ml/min• BP: 152/94, HR: 68Treatment:1. HCTZ 12.5-25mg QD2. Amlodipine 5mg QD3. Losartan 50mg QD4. Increase lisinopril to

40mg QD 100 0 0 0

Question 3•56 y.o. black male• Hx: diabetes, HTN, obstructive sleep apnea• Meds: metformin 1000mg BID, ASA 81mg QD, Gluctotrol XL 10mg QD• Labs: Cr = 1.0• BP: 148/88, HR: 70• Treatment:1. lisinopril 10mg QD2. losartan 50mg QD3. HCTZ 12.5-25mg QD4. Furosemide 20mg QD

100 0 0 0

Question 4•67 y.o. white male•Hx: HTN, DM, hyperlipidemia, GERD, BPH•Meds: finasteride 5mg QD, Zocor 80mg QD, terazosin 10mg QD, glimepride 4mg QD, Actos 45mg QD, lisinopril 10mg QD, metformin XR 2000mg/d, ASA 81mg QD•Labs: Cr: 1.2, microalbumin 10mg/L, K+ = 4.3•BP: 160/88,HR: 57Treatment

1. HCTZ 12.5-25mg QD2. Hydralazine 25mg BID3. Diltiazem XR 180mg QD4. Increase lisinopril to

20mg QD 100 0 0 0

Question 5•77 y.o. female•Hx: HTN, osteoporosis, angina, GERD•Meds: Reclast 5mg Qyear, Prilosec 40mg QD, Toprol XL 100mg QD, ASA, lisinopril/HCTZ 20/25mg QD•BP: 169/66, HR: 57, weight: 100 lbs, Cr = 0.3, K+ = 4.2Treatment:

1. Terazosin 2. Amlodipine 3. Hydralazine4. Furosemide 100 0 0 0

Question 6•78 y.o. female•Hx: Afib (c/o palpitations), HTN•Meds: warfarin, metoprolol 100mg BID, losartan 50mg QD•BP: 154/82 HR: 90Treatment1. Amlodipine 2. Diltiazem XR 3. Spironolactone4. Furosemide 100 0 0 0

Question 7•66 y.o. black male• Hx: HTN, s/p MI 2 months ago, hyperlipidemia• Meds: atorvastatin 20mg QD, ASA 81mg QD, Plavix 75mg QD, HCTZ 25mg QD, metoprolol 100mg BID• BP: 152/92, HR: 62Treatment1. Amlodipine2. Lisinopril3. Diltiazem XR4. Furosemide 100 0 0 0

Question 8•66 y.o. male•Hx: CKD, HTN, diabetes, PAD, hypothyroidism, hyperlipidemia•Meds: ASA 81mg QD, Lantus + Humalog, levothyroxine 0.1mg QD, Crestor 20mg QD, lisinopril 20mg QD•Labs: Cr = 2.8, K+ = 4.8•BP: 150/92, HR: 68Treatment

1. atenolol2. amlodipine3. HCTZ4. hydralazine 100 0 0 0

Question 9•70 y.o. male •Hx: HTN, LVH, GERD, TIA•Meds: Plavix 75mg QD, famotidine 20mg QD, HCTZ 25mg QD•BP: 154/86, HR: 70Treatment1. Metoprolol2. Lisinopril3. Amlodipine4. Spironolactone

100 0 0 0

Question 10•62 y.o. female•Hx: COPD, HTN, OA, obesity, CAD, occ symptomatic angina•Meds: Spiriva, Advair, ASA, Imdur 90mg QD, lisinopril 40mg QD, metoprolol XL 100mg QD, Nitrostat PRN•BP: 152/90, HR: 64 Treatment

1. HCTZ2. valsartan3. amlodipine4. terazosin

100 0 0 0

Summary

Age ≥ 60: goal BP is <150/90 Age <60: goal BP is <140/90 First line therapies

Thiazide, CCB’s, ACEI, ARB Thiazide or CCB recommended over

ACEI in blacks with diabetes Beta-blockers: not recommended as

first line therapy